Impact of Class of Obesity on Clinical Outcomes Following Fenestrated-Branched Endovascular Aneurysm Repair.

BACKGROUND: Obesity represents a prevalent and escalating health concern among vascular surgery patients. Evidence pertaining to the influence of body mass index (BMI) on clinical outcomes after fenestrated-branched endovascular aneurysm repair (B/FEVAR) remains unclear. This study aims to assess the effect of obesity on short- and midterm clinical outcomes among individuals undergoing B/FEVAR. METHODS: This was a single center retrospective analysis of all patients that underwent B/FEVAR from 2007 to 2020, with a median follow-up of 3.3 years [interquartile range 1.6-5.3]. Obesity was defined as body mass index (BMI) of ≥30 kg/m2. Patients were divided into non-obese (NO) and obese cohorts according to their BMI. Outcomes were compared between the two groups subsequently. RESULTS: A total of 264 patients, 96 obese and 168 NO were included. Patients with obesity were younger (72.8 ± 6.9 vs 76 ± 7.3 years, P< 0.001) but had a higher prevalence of diabetes mellitus (27.1% vs 12%, P= 0.01) and dyslipidemia (80.2% vs 68.5%, P=0.03). Both cohorts had similar rates of percutaneous access (37.5% for obese vs 35.1%, P=0.7), and no significant differences in the rate of conversion to open access (8.3% for obese vs 4.2%, P=0.16). Technical success was similar between the cohorts (89% for obese vs 86%, P=0.59). Major adverse events (MAEs) were higher in the NO group (13.1% vs 4.2%, P= 0.02). Patients in the obese cohort suffered more access site related infections (7.3% vs 1.2%, P= 0.01). All-cause mortality over 5 years was significant higher in the NO group (35.1% vs 21.9%, P= 0.02). No statistical differences were found in spinal cord injury or dialysis requirement rates. Furthermore, on follow-up at 5 years, endoleak, branch instability, and reintervention rates were not statistically different between the two cohorts. CONCLUSION: Patients with obesity are on average younger, however, were more likely to suffer access site infections compared to non-obese patients. They had increased survival rates on follow-up although rates of reinterventions and endoleaks were similar between the two cohorts. Our study demonstrates that despite higher comorbidities, patients with obesity had similar intraoperative success with reduced post operative mortality, however access site infections remains a significant clinical concern.

Mid-term Outcomes of the Viabahn VBX® Balloon-Expandable Covered Stent for Fenestrations During Complex Endovascular Aortic Aneurysm Repair (EVAR).

OBJECTIVES: The optimal bridging stent for fenestrations during complex endovascular aortic aneurysm repair (EVAR) has not been defined. At our institution, the Viabahn VBX® is frequently used given its availability and mechanical and heparin-bonding characteristics. This study aims to assess the performance of the Viabahn VBX® versus the iCast® balloon-expandable covered stents as bridging stents for fenestrations during complex EVAR. METHODS: A retrospective study of consecutive patients undergoing complex EVAR between 2015 and 2021 was performed. Celiac arteries (CAs), superior mesenteric arteries (SMAs), left renal arteries (LRAs), and right renal arteries (RRAs) stented with fenestrations were grouped according to the type of bridging stent, VBX® versus iCast®. Target vessels (TV) stented with a branch or scallop were excluded. The primary endpoints included primary patency and freedom from target vessel instability (TVI). RESULTS: A total of 292 patients undergoing complex EVAR were treated using VBX® or iCast® with a mean follow-up of 190 days (interquartile range [IQR], 36-384) for the VBX® cohort and 804 days (IQR, 384-1507) for the iCast® cohort. A total of 677 TVs were stented, including 134 (20%) CAs, 175 (26%) SMAs, 182 (27%) LRAs, 186 (27%) RRAs, and 12 (2%) additional vessels. Proximal reinforcement was more frequent with VBX than with iCast® stent (23% vs. 2.4%, P <.0001). There was no difference in primary patency rates at 2-year between VBX® and iCast® stent for CA (100% vs. 96.4%; P=.32), SMA (97.8% vs. 100%; P=.14) and renal arteries (96.7% vs. 99.4%; P=.11). There was no difference between VBX® and iCast® in the cumulative incidence of type Ic and type IIIc endoleaks (3.2% vs. 5.6%; P=.69) or freedom from TVI at 2 years. CONCLUSION: Viabahn VBX® stents are a safe and effective option as bridging stents in fenestrations during complex EVAR with comparable mid-term outcomes to iCast® stents. However, proximal stent reinforcement may be required with VBX stent to ensure adequate sealing at the fenestrations. Longer follow-ups and larger series are required to assess long-term outcomes and durability.

Influence of Bridging Stent Graft Implantation into the Renal Artery during Complex Endovascular Aortic Procedures on the Renal Resistance Index.

Comparative sonographic examination of the renal resistance index (RRI) can provide evidence of renal artery stenosis. The extent to which the RRI is changed after stent graft implantation is not known. The aim of this study was to investigate the influence of stent graft implantation into non-diseased renal arteries during endovascular treatment of pararenal aortic aneurysms on the RRI. Sonographic examinations of the kidneys were conducted using a GE ultrasound system. The evaluation was performed according to the European Society for Vascular Surgery (ESVS) 2D standard criteria. RRI values were determined in consecutive patients on the day before and after stent graft implantation and compared for each kidney. A total of 32 consecutive patients (73.9 ± 8.2 years, 5 females, 27 males) were treated with a fenestrated or branched aortic stent graft including bridging stent graft implantations into both renal arteries and received pre- and postinterventional examinations. Sonomorphologically, the examined kidneys were inconspicuous. The arborisation of the renal perfusion was preserved pre- and post-implantation. The RRI did not differ (0.66 ± 0.06 versus 0.67 ± 0.07; p = ns). Successful stent graft implantation into non-stenosed renal arteries did not lead to a relevant change in RRI. Therefore, the RRI is a suitable tool for assessing renal perfusion after fenestrated or branched endovascular aortic therapy.

iCover as Bridging Stent Graft in Fenestrated Endovascular Aortic Aneurysm Repair.

BACKGROUND: Complex endovascular repair with fenestrated or branched stent grafts is a common approach for treating various types of aortic aneurysms. Bridging stent grafts (BSs) are crucial in connecting aortic endoprosthesis to target vessels, yet current options have demonstrated significant complications. OBJECTIVE: This retrospective single-center study evaluates the initial outcomes and durability of the iCover stent graft (iCover-SG) when used as a BS in fenestrated endovascular aneurysm repair (FEVAR). METHODS: Retrospective analysis screened procedures for complex aortic aneurysms between August 2021 and January 2024. Patients who underwent FEVAR with iCover-SG as BS were included. Primary and secondary endpoints focused on freedom from iCover-SG-related target vessel instability, technical success, and postoperative outcomes. RESULTS: Within the cohort of 28 patients, 94 iCover-SGs were used as BS, supplying 87 target vessels. The freedom from iCover-SG-related target vessel instability throughout the study reached 94% (82/87). Technical success rates were notably high, with primary success achieved in 94% of cases and secondary success in 99%. Over the follow-up duration, there were instances necessitating reintervention related to iCover-SG, including 4 cases of endoleak, 2 cases of T1cEL, and 2 cases of T3cEL. In-hospital mortality was 7% (n=4), with 2 cases attributed to intraoperative complications. Importantly, no deaths were directly attributed to iCover-SG-related issues. CONCLUSION: The iCover-SG demonstrates promising initial outcomes as a BS in FEVAR, with high technical success rates and satisfactory rates of target vessel instability. Continued monitoring and further studies are warranted to assess long-term durability and outcomes. CLINICAL IMPACT: This study shows that the iCover stent graft achieves satisfactory technical success and target vessel stability in the short- and mid-term when used as a bridging stent graft in FEVAR procedures. Its successful integration into clinical practice broadens the range of available options, providing clinicians with more versatile tools for managing complex endovascular aortic aneurysms. This expanded selection of bridging stent grafts allows for more personalised treatment strategies, improving procedural precision and patient outcomes. The iCover stent graft's reliable performance highlights its potential as a valuable addition to current endovascular techniques, ultimately enhancing patient care in challenging cases.

Hybrid Approach: Combining Surgical Thrombectomy and AngioJet™ Aspirational Thrombectomy in Limb Graft Occlusion Post-FEVAR with Fenestrated Anaconda™ and in ePTFE Bypass Graft Occlusion.

Acute limb ischemia due to limb-graft occlusion (LGO) after fenestrated endovascular aneurysm repair (FEVAR) and acute bypass graft occlusion with an ePTFE graft pose critical challenges, necessitating prompt intervention to prevent limb loss. This paper discusses two cases of acute limb ischemia treated with a hybrid approach using the AngioJet™ Ultra Thrombectomy System as an adjunct to Fogarty thrombectomy. Case I involved a 69-year-old male post-FEVAR with contralateral iliac limb graft occlusion of the fenestrated Anaconda™, while Case II featured a 70-year-old male (ASA IV) post-bypass surgery (iliopopliteal arterial bypass with ePTFE Graft) with acute bypass graft occlusion. Both cases underwent successful recanalization using the AngioJet™ Ultra Thrombectomy System (ZelanteDVT™ 8F catheter, Solent™ Proxi 6F catheter) (Boston Scientific, Marlborough, MA, USA), combined with adjunctive techniques including Fogarty thrombectomy, balloon angioplasty, stenting, and local lysis. Immediate postoperative and follow-up assessments after 6 months revealed restored limb perfusion and improved clinical outcomes, with palpable pulses and improved ulcer healing. The aim of this treatment strategy is not only to alleviate limb ischemia but also to preserve future options in the event of graft failure. The use of the AngioJet™ Thrombectomy System in cases of LGO aims not only to clear the thrombus load but also to avoid the need for graft relining. In the case of acute arterial bypass graft occlusion in a patient with ASA IV, the goal of using the thrombectomy device is to preserve the native vessels for future procedures, such as long infragenual bypass, in addition to limb salvage. These cases demonstrate the efficacy of a hybrid surgical approach in managing acute limb ischemia following graft occlusion following FEVAR and bypass surgery. Long-term follow-up will further elucidate the durability of these interventions and their impact on limb salvage and overall patient outcomes. By combining mechanical thrombectomy with adjunctive techniques, such as balloon angioplasty and stenting, this hybrid approach offers a comprehensive solution to acute limb ischemia, addressing both the underlying occlusive pathology and ensuring optimal limb perfusion. Furthermore, the utilization of the AngioJet™ Ultra Thrombectomy System provides a minimally invasive yet effective method for thrombus removal, reducing procedural time and potential complications associated with open surgical techniques. As such, this approach represents a valuable addition to the armamentarium of treatments for acute limb ischemia, particularly in cases of graft occlusion following complex endovascular and bypass procedures.

Multicenter Study on Physician-Modified Endografts for Thoracoabdominal and Complex Abdominal Aortic Aneurysm Repair.

BACKGROUND: Physician modified endografts (PMEGs) have been widely used in the treatment of complex abdominal aortic aneurysm and thoracoabdominal aortic aneurysm, however, previous data are limited to small single center studies and robust data on safety and effectiveness of PMEGs are lacking. We aimed to perform an international multicenter study analyzing the outcomes of PMEGs in complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms. METHODS: An international multicenter single-arm cohort study was performed analyzing the outcomes of PMEGs in the treatment of elective, symptomatic, and ruptured complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms. Variables and outcomes were defined according to the Society for Vascular Surgery reporting standards. Device modification and procedure details were collected and analyzed. Efficacy outcomes included technical success and safety outcomes included major adverse events and 30-day mortality. Follow-up outcomes included reinterventions, endoleaks, target vessel patency rates and overall and aortic-related mortality. Multivariable analysis was performed aiming at identifying predictors of technical success, 30-day mortality, and major adverse events. RESULTS: Overall, 1274 patients were included in the study from 19 centers. Median age was 74 (IQR, 68-79), and 75.7% were men; 45.7% were complex abdominal aortic aneurysms, and 54.3% were thoracoabdominal aortic aneurysms; 65.5% patients presented electively, 24.6% were symptomatic, and 9.9% were ruptured. Most patients (83.1%) were submitted to a fenestrated repair, 3.6% to branched repair, and 13.4% to a combined fenestrated and branched repair. Most patients (85.8%) had ≥3 target vessels included. The overall technical success was 94% (94% in elective, 93.4% in symptomatic, and 95.1% in ruptured cases). Thirty-day mortality was 5.8% (4.1% in elective, 7.6% in symptomatic, and 12.7% in ruptured aneurysms). Major adverse events occurred in 25.2% of cases (23.1% in elective, 27.8% in symptomatic, and 30.3% in ruptured aneurysms). Median follow-up was 21 months (5.6-50.6). Freedom from reintervention was 73.8%, 61.8%, and 51.4% at 1, 3, and 5 years; primary target vessel patency was 96.9%, 93.6%, and 90.3%. Overall survival and freedom from aortic-related mortality was 82.4%/92.9%, 69.9%/91.6%, and 55.0%/89.1% at 1, 3, and 5 years. CONCLUSIONS: PMEGs were a safe and effective treatment option for elective, symptomatic, and ruptured complex aortic aneurysms. Long-term data and future prospective studies are needed for more robust and detailed analysis.

Long-term results of fenestrated and branched endovascular aneurysm repair for complex abdominal and thoracoabdominal aortic aneurysms in young and fit patients.

BACKGROUND: Endovascular repair of complex abdominal aortic aneurysms (CAAAa) and thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched devices (F/BEVAR) represents the first-line treatment in old or unfit patients. Currently, the widespread diffusion of these techniques has led to a progressive increase of complex endovascular procedures also in younger and fitter patients, but the related results have been only minimally reported, without long-term data. We investigated the long-term results of F/BEVAR for CAAA and TAAA repair in young and fit patients. METHODS: All consecutive patients, aged ≤70 years, who underwent F/BEVAR for CAAA and TAAA over the last 13 years at two tertiary institutions were included in the study. All subjects presented a low to intermediate risk according to the Society for Vascular Surgery clinical comorbidity grading system. The primary end points were technical and clinical success and late overall and aortic-related survival. Major complications and specific target vessel-related outcomes were investigated as secondary end points. RESULTS: A total of 183 patients (155 males [84.7%]; mean age, 64.5 ± 5.7 years; range, 33-70 years) underwent F/BEVAR during the study period, for a total of 167 degenerative (91.3%) and 16 postdissection (8.7%) aneurysms, including 44 (24%) juxtarenal, 33 (18%) pararenal, and 106 (58%) TAAAs. Technical and clinical success were achieved in 176 patients (96.2%) and 171 patients (93.4%), respectively. Four patients (2.2%) died perioperatively, of which two (1.1%) operated in emergency. Postoperatively, five patients (2.7%) presented permanent grade 3 spinal cord injury and three (1.6%) renal failure needing permanent dialysis. The mean follow-up was 65.7 ± 39.6 months (range, 1-158 months). The estimated overall and aortic-related survival at 12, 60, and 120 months was 94.0%, 85.1%, 72.2%, and 97.8%, 97.8%, 96.2%, respectively, and reintervention and branch instability-free survival at the same time points were 84.4%, 71.8%, 71.8%, and 93.2%, 86.3%, 72.2%, respectively. An aneurysm growth of >5 mm was detected in six patients (3.3%), and a sac shrinkage of >5 mm was achieved in 118 cases (64.5%). The Cox regression analysis demonstrated the need for unplanned procedure as the only risk factor for overall mortality (odds ratio, 3.331; 95% confidence interval, 1.397-7.940; P < .01]. CONCLUSIONS: F/BEVAR in young and fit patients led to low perioperative mortality and major morbidity rates and a favorable overall survival rate in the long-term, making this technique particularly appealing in such a subgroup of patients. The availability of long-term data derived from the results of young patients, may additionally provide helpful information to redefine the indications for treatment and allow future targeted device and technique improvements.

Practice patterns of antiplatelet and anticoagulant therapy after fenestrated/branched endovascular aortic repair.

OBJECTIVE: Antiplatelet and/or anticoagulant therapy are commonly prescribed after fenestrated/branched endovascular aortic repair (F/BEVAR). However, the optimal regimen remains unknown. We sought to characterize practice patterns and outcomes of antiplatelet and anticoagulant use in patients who underwent F/BEVAR. METHODS: Consecutive patients enrolled (2012-2023) as part of the United States Aortic Research Consortium (US-ARC) from 10 independent physician-sponsored investigational device exemption studies were evaluated. The cohort was characterized by medication regimen on discharge from index F/BEVAR: (1) Aspirin alone OR P2Y12 alone (single-antiplatelet therapy [SAPT]); (2) Anticoagulant alone; (3) Aspirin + P2Y12 (dual-antiplatelet therapy [DAPT]); (4) Aspirin + anticoagulant OR P2Y12 + anticoagulant (SAPT + anticoagulant); (5) Aspirin + P2Y12 + anticoagulant (triple therapy [TT]); and (6) No therapy. Kaplan-Meier analysis and Cox proportional hazards modeling were used to compare 1-year outcomes including survival, target artery patency, freedom from bleeding complication, freedom from all reinterventions, and freedom from stent-specific reintervention. RESULTS: Of the 1525 patients with complete exposure and outcome data, 49.6% were discharged on DAPT, 28.8% on SAPT, 13.6% on SAPT + anticoagulant, 3.2% on TT, 2.6% on anticoagulant alone, and 2.2% on no therapy. Discharge medication regimen was not associated with differences in 1-year survival, bleeding complications, composite reintervention rate, or stent-specific reintervention rate. However, there was a significant difference in 1-year target artery patency. On multivariable analysis comparing with SAPT, DAPT conferred a lower hazard of loss of target artery patency (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.27-0.84; P = .01). On sub-analyses of renal stents alone or visceral stents alone, DAPT no longer had a significantly lower hazard of loss of target artery patency (renal: HR, 0.66; 95% CI, 0.35-1.27; P = .22; visceral: HR, 0.31; 95% CI, 0.05-1.9; P = .21). Lastly, duration of DAPT therapy (1 month, 6 months, or 1 year) did not significantly affect target artery patency. CONCLUSIONS: Practice patterns for antiplatelet and anticoagulant regimens after F/BEVAR vary widely across the US-ARC. There were no differences in bleeding complications, survival or reintervention rates among different regimens, but higher branch vessel patency was noted in the DAPT cohort. These data suggest there is a benefit in DAPT therapy. However, the generalizability of this finding is limited by the retrospective nature of this data, and the clinical significance of this finding is unclear, as there is no difference in survival, bleeding, or reintervention rates amongst the different regimens. Hence, an "optimal" regimen, including the duration of such regimen, could not be clearly discerned. This suggests equipoise for a randomized trial, nested within this cohort, to identify the most effective antiplatelet/anticoagulant regimen for the growing number of patients being treated globally with F/BEVAR.

Standardized approach for four-fenestrated physician-modified endograft to treat complex abdominal aortic aneurysms using Valiant Captivia.

We describe the feasibility and safety of a standardized approach for four-fenestrated physician-modified endograft (PMEG) placement to treat complex abdominal aortic aneurysms using the Valiant Captivia platform (Medtronic). The standardization is based on specific selection criteria for anatomical feasibility, measurement method, and modification technique of a single endograft type. Six cases (two juxtarenal, two pararenal, and two type IV thoracoabdominal aneurysms) were treated, with 24 target vessels incorporated with fenestrations. Four cases were treated in an urgent setting and two were elective. The time modification required was 121 ± 18 minutes. Technical success was 100%, with no mortality or complications at 30 days. Postoperative computed tomography at 3 months demonstrated complete aneurysm exclusion, without a type I or III endoleak, no main graft- or fenestration-related loss of integrity, and no target vessel misalignment or stent fracture. The present standardized approach seems safe and feasible and might represent an initial benchmark for comparison with future studies.

Use of a novel device for intraoperative wire management during fenestrated endovascular type 4 thoracoabdominal aortic aneurysm repair.

Endovascular procedures are minimally invasive approaches to treat conditions affecting blood vessels without the need for large incisions. The benefits are less blood loss and faster recovery. One condition commonly treated endovascularly is aortic aneurysmal disease often secondary to atherosclerosis or chronic hypertension. As endovascular aneurysm repair becomes increasingly complex and sophisticated, the intraoperative organization and management of wires from multiple access sites becomes paramount. Often, the physician selects visceral or great vessels for delivery of stent grafts to maintain vessel patency. Loss of wire in critical target vessels and wire contamination pose significant patient risks. WireWatch (BioTex Inc. Houston, Texas, USA) is a novel device designed for intraoperative wire management to improve surgical field organization, provide wire stabilization, and prevent dropped wires. This case describes its use in a 73-year-old female undergoing a fenestrated endovascular aneurysm repair of 5.6 cm types IV thoracoabdominal aortic aneurysm.

Technical Aspects and Outcome of Multi-Staged and Single-Staged Thoracoabdominal Fenestrated Endovascular Aortic Repair.

PURPOSE: In some cases of endovascular thoracoabdominal or juxtarenal aortic aneurysm repair, a thoracic endograft in combination with a fenestrated renovisceral device may be needed in order to create a sufficient proximal landing zone. This study aimed to evaluate the technical aspects and postoperative morbidity of a single- or 2-stage approach. METHODS: Eighty-seven consecutive patients undergoing thoracic endovascular aortic repair (TEVAR) in combination with elective fenestrated repair (fenestrated endovascular aortic repair [FEVAR]; fenestrated Anaconda device) from 2015 to 2022 were included in this retrospective bicentric study. Underlying pathologies, aortic morphology, technical details, and postoperative morbidity were recorded. RESULTS: Single-staged ("1S," n=61) and 2-staged ("2S," n=26) interventions were compared. Indications were thoracoabdominal aneurysms (TAAAs) (Crawford I-IV) (n=56, 64%) and juxtarenal aneurysms (n=31, 36%). In 2S, the proportion of TAAA was higher than in 1S (2S: 77%, 1S: 59%; p=0.001). In 2S, the covered length of the descending aorta was longer (1S: 128±60 mm, 2S: 202±64 mm; p=0.003). Temporary aneurysm sack perfusion (TASP) was established in 11 (18%) of 1S and 1 (4%) of 2S patients (p=0.079), as well as cerebrospinal fluid (CSF) drainage catheter in 48 (79%) of 1S and 19 (73%) of 2S. The rate of spinal cord ischemia (SCI) and the severity of SCI were not different in both groups, with a total of 3 cases of persisting paraplegia. The rate of access complications was higher in 2S (n=6, 23%) than in 1S (n=4, 7%; p=0.027). Postoperative 30 day morbidity did not significantly differ in both groups and neither did 30 day mortality (4.6% in 1S vs 3.8% in 2S; p=0.083). CONCLUSION: The combination of TEVAR and FEVAR using a fenestrated endograft is feasible and safe. Aortic morphology does not change significantly after endovascular repair. A single-staged strategy is feasible with excellent results, especially in Crawford IV, Crawford V, or juxtarenal aneurysms. Two-staged repair is recommended in cases with long aortic coverage and a higher American Society of Anesthesiologists (ASA) class. Follow-up data are needed to evaluate the long-term stability of the TEVAR/FEVAR interconnection. CLINICAL IMPACT: Our study has revealed the safety and efficacy of the combination of TEVAR and FEVAR in the treatment of TAAAs and juxtarenal aneurysms with compromised supravisceral landing zones. A single-staged concept is not necessary in all cases. Staged procedures may reduce postoperative morbidity in cases with long aortic coverage and higher ASA class.

The Utility of Three-Dimensional Printing in Physician-Modified Stent Grafts for Aortic Lesions Repair.

Background: Three-dimensional (3D) printing is becoming increasingly popular around the world not only in engineering but also in the medical industry. This trend is visible, especially in aortic modeling for both training and treatment purposes. As a result of advancements in 3D technology, patients can be offered personalized treatment of aortic lesions via physician-modified stent grafts (PMSG), which can be tailored to the specific vascular conditions of the patient. The objective of this systematic review was to investigate the utility of 3D printing in PMSG in aortic lesion repair by examining procedure time and complications. Methods: The systematic review has been performed using the PRISMA 2020 Checklist and PRISMA 2020 flow diagram and following the Cochrane Handbook. The systematic review has been registered in the International Prospective Register of Systematic Reviews: CRD42024526950. Results: Five studies with a total number of 172 patients were included in the final review. The mean operation time was 249.95± 70.03 min, and the mean modification time was 65.38 ± 10.59 min. The analysis of the results indicated I2 of 99% and 100% indicating high heterogeneity among studies. The bias assessment indicated the moderate quality of the included research. Conclusions: The noticeable variance in the reviewed studies' results marks the need for larger randomized trials as clinical results of 3D printing in PMSG have great potential for patients with aortic lesions in both elective and urgent procedures.

Individualizing Surveillance after Endovascular Aortic Repair Using a Modular Imaging Algorithm.

OBJECTIVES: Surveillance after endovascular aortic repair (EVAR) and fenestrated EVAR (FEVAR) is mainly directed by one-size-fits-all approaches instead of personalized decision making, even though treatment strategies and often endografts themselves are tailor-made to adjust for individual patients. We propose a modular imaging algorithm that escalates surveillance imaging based on invasiveness and need. MATERIALS AND METHODS: In this retrospective observational study of single-center data, results of a modular imaging algorithm were analyzed. The algorithm is characterized by initiating the examination with standard B-mode then transitioning to Duplex ultrasound, B-Flow, and CEUS. Additional CT(A) studies are conducted where required. The study population included both patients receiving EVAR or FEVAR. A comparative analysis was conducted regarding endoleak detection. RESULTS: The study population included 28 patients receiving EVAR and 40 patients receiving FEVAR. They accounted for 101 follow-up visits, which led to 431 distinct imaging studies. CEUS has the highest endoleak detection rate, followed by CTA and B-Flow. Duplex ultrasound and B-Flow resulted in 0 and 1 false positive cases, respectively, considering CEUS the reference standard. In a select group of six patients, CEUS was omitted after endoleaks were displayed by Duplex ultrasound or B-Flow, leading to a successful type II coiling and no aneurysm-related adverse events. CONCLUSIONS: The proposed modular algorithm showed great potential to incorporate principles of personalized medicine in surveillance after endovascular aortic treatment. Since Duplex ultrasound and B-Flow rarely cause false positive endoleaks, more resource-intensive and invasive imaging studies such as CEUS and CTA can be omitted after positive identification.

Multicentric Use of Commercially Available Infrarenal Endografts During Fenestrated Endovascular Aortic Repair: A Feasibility Study.

PURPOSE: This study aimed to assess the feasibility and short-term outcomes of different manufactured proximal and distal stent graft components during fenestrated endovascular aortic repair (FEVAR). MATERIALS AND METHODS: A multicenter retrospective review was conducted at 3 aortic centers, involving all consecutive patients who underwent FEVAR utilizing a customized Dacron-based tubular proximal and a distal bifurcated polytetrafluoreten (PTFE)-based commercially available stent grafts. Primary outcomes were 30 day mortality, major adverse events, and technical and clinical success. Secondary outcomes assessed stent graft migration, occurrence of types I/III endoleak, and reintervention. RESULTS: A total of 23 FEVAR cases across all centers were included in this study. Technical success was achieved in all cases, with a median procedure time of 183 (153-244) minutes. There were no major adverse events, except for 1 transient acute renal failure. The median follow-up period was 23 (17-28) months. All target vessels retained patent with the exception of 1 right renal fenestration that showed signs of kinking at the first follow-up, and despite secondary intervention with relining and distal extension, there was an occlusion afterward and 1 hepatic artery with a separate fenestration. This and 1 successful relining of a superior mesenteric artery kink were the only reinterventions in this cohort. One case of persistent type 1b endoleak was reported in a patient with chronic type B aortic dissection, which resolved with distal extension on the external iliac artery 5 months after the index procedure. No deaths occurred throughout the follow-up with, and there were no signs of stent graft migration or type 3 endoleak. CONCLUSION: The use of commercially available PTFE-based bifurcated stent grafts to extend distally the tubular graft appears to be a feasible approach during FEVAR, with promising short-term outcomes. Further studies are necessary to define the applicability of this solution and evaluate long-term outcomes. CLINICAL IMPACT: This multicentric study on fenestrated endovascular aortic repair (FEVAR) demonstrates the feasibility and good short-term outcomes of utilizing a PTFE-based commercially available stent graft to extend the proximal tubular custom-made fenestrated stent graft. The high technical success rate, absence of major adverse events, and low occurrence of complications such as stent graft migration and endoleaks highlight the potential clinical benefits of this approach with an off-the-shelf distal extension whose delivery system does not cross the fenestrations intraoperatively.

Prospective randomized pilot trial comparing prophylactic and therapeutic cerebrospinal fluid drainage during complex endovascular thoracoabdominal aortic aneurysm repair.

BACKGROUND: Endovascular techniques have transformed the management of thoracoabdominal aortic aneurysms (TAAAs). However, spinal cord ischemia (SCI) remains a prevalent and devastating complication. Prophylactic drainage of cerebrospinal fluid (CSF) is among the proposed strategies for prevention of SCI. Although prophylactic CSF drainage is widely used and conceptually attractive, prophylactic CSF drains have not been demonstrated to definitively prevent the occurrence nor mitigate the severity of SCI in endovascular TAAA repair. Whether or not outcomes of prophylactic drains are superior to therapeutic drains remains unknown. This pilot study was performed to determine the feasibility of a randomized clinical trial designed to investigate the role of prophylactic vs therapeutic CSF drains in the prevention of SCI in patients undergoing endovascular TAAA repair using branched and fenestrated endovascular aortic repair (FBEVAR). METHODS: This was a prospective multicenter randomized pilot clinical trial conducted at The University of Alabama at Birmingham and The University of Massachusetts. Twenty patients were enrolled and randomized to either the prophylactic drainage or therapeutic drainage groups, prior to undergoing FBEVAR for extensive TAAAs and arch aortic aneurysms. This was a pilot feasibility study that was not powered to detect statistical differences in clinical outcomes. The primary outcome was feasibility of randomization and compliance with a shared lumbar drain protocol. Secondary outcomes included rate of drain complications and SCI. RESULTS: Twenty patients were enrolled and successfully randomized, without any crossovers, to either the control cohort (n = 10), without prophylactic drains, or the experimental cohort (n = 10), with prophylactic drains. There were no differences in age, comorbidities, or history of prior aortic surgery across the cohorts. All patients were treated with FBEVAR. Aneurysm classifications were as follows: Extent I (10%), Extent II (50%), Extent III (35%), and Extent IV (5%). The average length of aortic coverage was 207 ± 21.6 mm. The length of aortic coverage did not vary across cohorts, nor did procedural times or blood loss volume. Compliance with the SCI prevention protocol was 100% across both groups. Within the prophylactic drain cohort, one patient experienced an adverse event related to lumbar drain placement, manifested as an epidural hematoma requiring laminectomy, without neurologic deficit (n = 1/10; 10%). There was one SCI event (n = 1/20; 5%), which occurred in the prophylactic drain cohort on postoperative day 9 following an episode of hypotension related to a gastrointestinal bleed. CONCLUSIONS: The role of prophylactic CSF drains for the prevention of SCI following endovascular TAAA repair is a topic of ongoing research, with many current practices based on expert opinion and experience, rather than rigorous scientific data. This study demonstrates the feasibility of a multicenter randomized clinical trial to evaluate the role of prophylactic vs therapeutic CSF drains in the prevention of SCI in patients undergoing endovascular TAAA repair.

Report of a semi-branched stent-graft to treat a type 1a endoleak after failed EVAR.

BACKGROUND: Endovascular techniques are advancing with the change of treatment paradigm for abdominal aortic aneurysms. Fenestrated EVAR (fEVAR) and branched EVAR (bEVAR) are used for complex aortic aneurysm repair. Both fEVAR and bEVAR have their own advantages and disadvantages. Semi-branches are a new feature that attempt to combine the advantages of both fEVAR and bEVAR. TECHNIQUE: We describe the use of a 4-vessel semi-branched EVAR in a failed EVAR case with a type 1a endoleak. CONCLUSION: The novel feature of semi-branches in custom-made EVAR devices in endovascular aortic treatment following failed EVAR appear to be a feasible option.

Incidence of endoleak type IA in patients undergoing chimney endovascular aortic repair (ChEVAR) vs. standard endovascular repair.

Objectives: Almost half of endovascular aortic aneurysm repair (EVAR) procedures are performed in hostile anatomy, increasing the risk of procedure related complications such as type IA endoleaks, which may be prevented with the chimney technique in EVAR (ChEVAR). Our aim is to describe the differential characteristics between EVAR in favorable anatomy and ChEVAR in hostile necks. Materials and methods: A cohort of patients with infrarenal abdominal aortic aneurysms (AAA) that were treated with EVAR or ChEVAR were included. The primary outcome was the incidence of type IA endoleak. Secondary outcomes were the rate of chimney occlusion, reintervention, migration, rupture, acute limb ischemia, sac growth, and aneurysm-related mortality during the follow-up period. Results: . With a median follow-up of 11.5 months, 79 patients were treated with EVAR and 21 with ChEVAR. The overall age was 76.49 ± 7.32 years old, and 82% were male. The ChEVAR cohort had a higher prevalence of tobacco use than the EVAR cohort (38.1% vs. 17.7%, p = 0.041), and a shorter neck (7.88 mm ± 5.73 vs 36.28 mm ± 13.73, p<0.001). There were no differences in type IA endoleak incidence between the groups (a single endoleak type IA in the EVAR group, p = 0.309). One patient experienced an asymptomatic chimney occlusion in the ChEVAR group, and another patient required a reintervention due to chimney occlusion. Sac regression and reinterventions were not different between groups. There were no migration, rupture, acute limb ischemia, or aneurysm-related mortality events. Conclusions: . In patients with abdominal aortic aneurysms, ChEVAR in hostile necks had similar event rates to EVAR in favorable necks.

Objetivos: Aproximadamente la mitad de las reparaciones endovasculares de aneurisma de aorta abdominal (AAA) son realizadas en anatomías hostiles, incrementando el riesgo de complicaciones como endoleaks tipo IA. La técnica con chimeneas (ChEVAR) es una alternativa para disminuir el riesgo de complicaciones en cuellos hostiles. Nuestro objetivo es comparar ambas técnicas (ChEVAR y reparación endovascular convencional [EVAR]) en nuestra medio. Materiales y métodos: Se realizó un trabajo de cohorte retrospectivo en pacientes con AAA tratados con EVAR o ChEVAR. El punto final primario fue la incidencia de endoleak tipo IA. Los puntos finales secundarios fueron la incidencia de oclusión de chimeneas, reintervención, migración, ruptura del saco, isquemia aguda de miembros, crecimiento del saco o mortalidad asociada al aneurisma durante el seguimiento. Resultados: Tras una mediana de seguimiento de 11,5 meses, 79 pacientes fueron tratados con EVAR y 21 con chEVAR. La edad promedio fue de 76,49 ± 7,32 años y 82% fueron de sexo masculino. Los pacientes con chEVAR tuvieron mayor prevalencia de consumo tabáquico que los pacientes con EVAR (38,1% vs. 17,7%, p=0,041) y un cuello más corto (7,88 mm ± 5,73 vs. 36,28 mm ± 13,73, p<0,001). No hubo diferencia de endoleak tipo IA entre los grupos. Dos pacientes presentaron la oclusión total de la chimenea, uno de los cuales requirió reintervención. No hubo diferencias en la regresión del tamaño del saco, así como tampoco hubo eventos de migración, ruptura, isquemia del miembro o mortalidad asociada al aneurisma. Conclusiones: En pacientes con AAA, la técnica ChEVAR en cuellos hostiles tuvo eventos similares que EVAR en cuellos favorables.